Pediatric Orthopaedic Surgery Associates

Demographics / Health History

Patient Information

Gender* (as indicated by insurance company)  
Is patient over 18 years of age?*

Who Referred You?
Who is your Primary Care Physician (PCP)?
Parent Information
Mother Employed?

Mother’s address same as Patient’s?*

Father Employed?

Father’s address same as Patient’s?*

Parent's Marital Status*

Is this person older than 18 years?*

Insurance Information
Primary Insurance
Do you have insurance (including Medicaid and Medicare)?*

Reason for Appointment
Developmental History (if less than 5 years old)
Can your child sit?

Can your child

Other Information
What is your child’s pain threshold?

Do you have to cut tags out of your child’s clothing?

Allergies to medications, X-ray dye, metals and/or soaps?

Please list any food allergies (i.e. gluten, milk intolerance, etc.)

Is the child currently taking prescribed medications or over-the-counter supplements?

Social History
Any potential exposure to Smoking/Smokeless Tobacco, Vaping/E-cigarettes in the home?

Family History (check where applicable) –
Anesthesia Problems

Cancer -

Bleeding/Clotting (DVT)


Heart Disease

High Blood Pressure

Malignant Hyperthermia


Patient Past Medical History - check all that apply

Procedure / Surgery History
Please list all past procedures / surgeries -

Is there anything else you would like POSA to know about your child?

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